Anatomical model and method for surgical training

ABSTRACT

Implementations relate to anatomical models and surgical training. In some implementations, an anatomical training model includes a base portion and a top portion that form a hollow space between the base portion and top portion. A plurality of holes are positioned in the top portion. The model includes a plurality of cannula supports, where each cannula support is aligned with one or more corresponding holes in the top portion.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application claims priority to U.S. patent application Ser. No.15/190,133, filed Jun. 22, 2016, entitled “Anatomical Model and Methodfor Surgical Training,” which is a continuation of U.S. patentapplication Ser. No. 13/968,253, filed Aug. 15, 2013, entitled“Anatomical Model and Method for Surgical Training,” which claimspriority to U.S. Provisional Application No. 61/684,376, filed Aug. 17,2012, all of which are incorporated herein by reference in theirentireties.

COPYRIGHT NOTICE

A portion of the disclosure of this patent document contains materialwhich is subject to copyright protection. The copyright owner has noobjection to the facsimile reproduction by anyone of the patent documentor the patent disclosure, as it appears in the Patent and TrademarkOffice patent file or records, but otherwise reserves all copyrightrights whatsoever.

BACKGROUND

Disclosed features concern medical training equipment and methods, andmore particularly medical training equipment and methods used fortraining in minimally invasive surgical procedures and techniques.

Minimally invasive surgical instrument port placement in a patient'sanatomy, setup positioning of a minimally invasive surgical roboticsystem, and coupling the robotic system to cannulas positioned in theports (“docking” the robot to the cannulas) are important tasks forsurgeons and medical personnel to learn. Physical anatomic modelsdedicated for use in training these tasks or that provide standardizedways to evaluate these tasks do not exist. Current anatomical simulationmodels (e.g., from the Chamberlain Group, Limbs & Things LTD, PacificResearch Laboratories, Inc. (Sawbones®), ProMIS™ Simulator from CAEHealthcare of CAE, Inc., SimSurgery® SEP products, and the like) maysimulate a portion of an abdomen, but such models do not providefeatures associated with these tasks or the necessary standardizationrequired to measure performance parameters over time and populations. Insome cases, for example, port locations on traditional laparoscopicmodels may not be appropriate for robotic surgery. Furthermore, many ofthe existing models have instrument handles (such as laparoscopic toolhandles) rigidly attached to port locations so that robotic trocars orother components cannot be attached to the ports.

The solutions developed thus far have not been specifically targeted torobotic surgery and instead have tried to encompass general surgery,laparoscopic surgery, and to a limited extent robotic surgery. This lackof dedicated robotic surgical training equipment has led to trainingexercises that are not ideally suited for the unique considerations ofrobotic surgery. For example, most other systems use a “skin” to layover large openings in an abdomen model, and port locations must beplaced through this large piece of skin. This situation often leads toonly a single set of holes and lack of instruction through differentchoices, setups, etc. Students are not provided the opportunity to tryvarious port placement patterns and to learn the benefits anddisadvantages of specific patterns vis-a-vis a particular surgical taskto be performed.

During training to use a minimally invasive surgical system, manysurgeons and medical personnel initially have difficulty with portplacement, robot setup, and cannula docking tasks, and such difficultymay needlessly extend operating times and may even affect a surgeon'swillingness to adopt such technology. In addition, personnel associatedwith training these tasks have identified a lack of proficiency in portplacement and cannula docking as the major limiter for useful trainingoutside of a dedicated training facility, such as at a hospitallocation. What is needed is dedicated training equipment and associatedprocedures to help surgeons and other medical personnel becomeproficient in these and related tasks.

SUMMARY

Implementations of the present application relate to anatomical modelsand surgical training using such a model. In some implementations, ananatomical training model includes a base portion and a top portion thatform a hollow space between the base portion and top portion. Aplurality of holes are positioned in the top portion. The model includesa plurality of cannula supports, where each cannula support is alignedwith one or more corresponding holes in the top portion. For example,each cannula support can be configured to hold a cannula that ispositioned through the hole, in simulation of the various locations in apatient's body wall at which cannulas may be placed.

Various implementations of the model are described. In some examples,the plurality of holes are greater in number than required by surgicalprocedures using the model. At least one of the plurality of holes canhave one size to accommodate one size of instrument cannulas, and atleast one of the plurality of holes can have a different size toaccommodate a different size of instrument cannulas. In someimplementations, the cannula supports include at least one cannulasupport piece positioned below one or more of the corresponding holesand above the bottom portion to simulate a patient body wall for one ormore instruments inserted through at least one of the holes in the topportion. In other implementations, each of the cannula supports ispositioned in a corresponding one of the plurality of holes in the topportion. For example, each of the cannula supports can include aflexible piece including an annular membrane for holding a cannulainserted through the cannula support and the corresponding hole. Someimplementations can include a membrane positioned over the top portionand the plurality of holes.

The base portion of the anatomical model can include a platformproviding at least one surgical site to receive one or more instrumentsinserted in one or more corresponding holes in the top portion. Theplatform can be removable from the base portion in some implementations.The surgical site can be provided at a known position and orientation onthe platform with respect to the plurality of holes to act as a fixedregistration location for placement of one or more cannulas in one ormore of the plurality of holes. For example, the platform can includestructures at different locations of the platform to which the surgicalsite is operative to be attached, allowing varied positional placementof the at least one surgical site with respect to the plurality of holesin the top portion. The at least one surgical site can include, forexample, a component having a soft material simulating tissue forsurgical manipulating tasks, and/or a component having a curved pathwayand one or more pieces movable along the curved pathway.

In some implementations, an anatomical training model includes a baseportion including a removable platform providing at least one surgicalsite, and a top portion coupled to the base portion to form a hollowspace between the base portion and the top portion. The top portionincludes a plurality of holes each sized to receive one or more cannulasdirected toward the surgical site. In various implementations, thesurgical site can be provided at a known position and orientation on theplatform with respect to the plurality of holes to act as a fixedregistration location for placement of one or more cannulas in one ormore of the plurality of holes. The platform can include structures atdifferent locations of the platform to which the at least one surgicalsite is operative to be attached, allowing varied positional placementof the surgical site with respect to the plurality of holes in the topportion.

In some implementations, a surgical training method includes measuringone or more parameters associated with one or more tasks, where the oneor more tasks are performed with reference to an anatomical model andinclude at least one of: surgical instrument port placement, surgicalrobot arm setup, and cannula docking. An automatic comparison isperformed between the measured one or more parameters and correspondingone or more stored parameters associated with the one or more tasks, andan evaluation is output that is based on the automatic comparison. Invarious implementations, the corresponding stored parameters aremeasured at a first time, and the measuring of the parameters isperformed at a second time later than the first time. The parametersmeasured at the first time can be associated with a first personperforming the tasks, and the parameters measured at the second time canbe associated with a second person performing the one or more tasks.Alternatively, the parameters measured at the first time and the secondtime can be associated with a particular person performing the tasks.Outputting an evaluation can include outputting a score that is based onthe time needed to perform the one or more tasks, and/or positioning ormovement of surgical procedure components during the tasks.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a perspective view of an anatomical model;

FIGS. 2A and 2B are a diagrammatic perspective views that illustratessurgical ports and associated cannula supports in an anatomical model;

FIG. 3A is a perspective view of a cannula support;

FIGS. 3B and 3C are perspective views of a cannula support and singlesite port;

FIG. 4 is top perspective view of an anatomical model;

FIG. 5 is a diagrammatic top view of port placement grids;

FIG. 6 is a perspective view of a surgical robot with an anatomicalmodel;

FIG. 7 is a perspective view of one example of a surgical exercise taskplatform;

FIG. 8 is a perspective view of another example of a surgical exercisetask platform;

FIG. 9 is a perspective view of one example of an anatomical model baseportion and a surgical exercise task platform;

FIG. 10 is a perspective view of another example of the anatomical modeland a platform similar to the platform of FIG. 8;

FIG. 11 is a perspective view of an interior of one embodiment of ananatomical model;

FIG. 12 is a perspective view of one example of an illustrative taskexercise component for a platform similar to the platform of FIG. 8;

FIGS. 13A to 13H show example illustrative task exercise componentswhich can be used for the platform in the anatomical model;

FIG. 14 is a flow chart that illustrates an example method forevaluating patient-side surgical task exercises;

FIG. 15 is a flow chart that illustrates an example method forevaluating surgical task operations; and

FIG. 16 is a diagrammatic view of an example system for performingsurgical exercise tasks and evaluation.

DETAILED DESCRIPTION

The present application discloses features relating to anatomical modelsused in surgical procedure training exercises, and relating to methodsevaluating performances of surgical procedures using an anatomicalmodel. Various disclosed implementations of anatomical models provideand teach realistic positioning, placement, and use of cannula ports andsurgical sites for particular surgical procedures. The anatomical modelprovides a known configuration to be used for surgical training,including positioning cannula ports and surgical sites at known,consistent locations. Implementations provide consistent and repeatablesurgical task exercises to allow standardized and consistentmeasurement, evaluation, and comparison of performances of surgicaltechniques by many different trainees. Disclosed training methodsinclude measurement and evaluation of surgical exercise tasks such asport placement, robot setup, cannula docking tasks, and surgical taskoperations, allowing trainees' performances to be evaluated and enablingtrainees to improve their skills more efficiently.

Some implementations are described using a robotic surgery system suchas a da Vinci® Surgical System (e.g., a Model IS3000, marketed as the daVinci® Si™ HD™ Surgical System), commercialized by Intuitive Surgical,Inc. of Sunnyvale, Calif. Knowledgeable persons will understand,however, that features disclosed herein may be embodied and implementedin various ways, including robotic and, if applicable, non-roboticembodiments and implementations. Implementations on da Vinci® SurgicalSystems (e.g., the Model IS3000; the Model IS2000, commercialized as theda Vinci® S™ HD™ Surgical System) are merely exemplary and are not to beconsidered as limiting the scope of the inventive aspects disclosedherein.

FIG. 1 is a perspective view of an anatomical model 101 in accordancewith some implementations disclosed herein. As shown, the modelresembles an insufflated human abdomen and pelvic region. For example,the size and shape of the model 101 can be determined from values inmedical literature and cadaver measurements. Various embodiments ofmodel 101 may be sized differently to simulate various body sizes (e.g.,pediatric, small female, average, large male, obese, etc.).

The model includes a top portion 102 a and a base portion 102 b, whichfit together and form an outer shell of the model. The model has ahollow interior between top portion 102 a and base portion 102 b.Alternatively, the outer shell of the model is formed from a singlepiece, or from three or more pieces.

Several port placement openings are formed in the top portion 102 a ofthe model, and these openings allow one or more cannulas to bepositioned in the model at various port locations. As shown in theexample embodiment of FIG. 1, the openings can include one or more setsof holes in top portion 102 a to allow operating instrument cannulas topass therethrough and directed instruments toward a surgical site insidethe anatomical model 101. In this example, one set of holes 103 ispositioned in top portion 102 a to accommodate cannulas for surgicalinstruments that are operating instruments, e.g., instruments used tocontact and manipulate a simulated surgical site within the model. Forexample, operating instruments can include conventional laproscopinginstruments and/or instruments having manipulable needle driver,stapler, scalpel, vessel sealer, scissors, forceps, grasping implements,cauterizing tools, irrigation tools, suction tools, etc. A second set ofholes 104 are also positioned in top portion 102 a to accommodatecannulas for surgical instruments that are endoscopes or other camerainstruments, e.g., instruments providing a camera and/or illumination toprovide images of the surgical site to the surgeon or trainee. In someimplementations, smaller camera instruments can be positioned throughthe smaller holes 103.

In this example, holes 104 can be positioned along a longitudinalcenterline of the top portion 102 a, in accordance with an aspect of acamera port placement technique that similarly positions the camerainstrument port generally at a patient's abdominal centerline. In otherembodiments, holes 104 may be at other locations in the model. As shown,holes 103 are positioned in top portion 102 a laterally of the model'slongitudinal centerline. Holes 103 simulate the various locations atwhich operating instrument cannulas can be placed.

The various holes are placed to allow a trainee to place surgicalinstrument ports in the model in accordance with recommended surgicalinstrument port placement for various robotic surgery procedures, suchas radical prostatectomy, radical hysterectomy, partial nephrectomy,multi- or single-port cholecystectomy, etc. In some embodiments, one ormore holes 103 and/or 104 are placed in base portion 102 b to simulateaccess to a surgical site from a direction that originates at baseportion 102 b. The holes 103,104 can be placed at various locations invarious embodiments to accommodate the learning objective or objectivesto be supported by the use of the particular model embodiment. Invarious implementations, the density and/or number of holes in topportion 102 a can vary to allow for more or fewer port location options.

In some implementations such as the embodiment shown, there can be agreater number of holes 103,104 provided in the top portion 102 a thanare required for a surgical procedure (or any surgical proceduresintended to be practiced using the model), so that a trainee is requiredto select the proper subset of holes to use in order to reach a surgicalsite inside the simulated patient. Thus, various port placements can beexplored for a certain surgical task. In this way a surgeon can morefully understand the relative advantages and disadvantages of one portplacement strategy versus another port placement strategy for a certainsurgical task.

Furthermore, the anatomical model 101 provides an array of holes 103 and104 which can be specifically-tailored in their positions to surgicalinstruments of a particular robotic surgical system, allowing trainingto be provided for a robotic system using an array of port locations.

A simulated surgical site platform 106 can be positioned inside themodel's hollow interior. As explained in more detail below, platform106, or objects placed on platform 106, may have various configurationsto simulate various surgical procedures at various positions inside themodel. In this way, the single model 101 can be used for surgical porttraining for various different surgical procedures.

The anatomical model 101 can also be useful for a range of othersurgical task exercises. For example, the model can be used for remotecenter alignment of instruments with the abdomen body wall, instrumentexchange, camera and instrument insertion under direct vision, othertraining activities related to patient side skills (suture exchangeusing a laparoscopic tool, retraction using a laparoscopic tool by anassistant, etc.), understanding and illustration of workspace limits bythe surgical instruments, setup conditions to avoid collisions ofexternal robot arms, etc.

FIG. 2A is a diagrammatic perspective view that illustrates surgicalports in the model and associated cannula supports. In this example, acannula support piece 201 is placed below and aligned with a set of theholes 103, 104 to simulate the patient's body wall. When a cannula isinserted through a hole 103 or 104 and the associated piece 201, thepiece 201 acts as a support for the cannula and holds the cannula in amanner similar to the way a patient's body wall supports a cannula(e.g., a little floppy). By simulating the way a cannula is supported bya patient's body wall, medical personnel may be trained in a realisticsituation to position, align, and dock a surgical robot manipulator toan associated cannula.

In some examples, piece 201 may be made of various materials such asfoam or rubber (e.g., polyurethane). Different materials havingdifferent properties (e.g., stiffness) may be used to simulate differentbody wall characteristics at corresponding locations on the model. Forexample, one material may be used to simulate the umbilicus, and asecond material may be used to simulate the anterior abdominal muscles.In some implementations, piece 201 is sized to have thickness tosimulate the patient's body wall thickness. A relatively thicker piece201 may be used in a relatively larger model 101 to simulate arelatively larger patient, whereas a relatively thinner piece 201 may beused in a relatively smaller model 101 to simulate a relatively smallerpatient. In a single anatomical model, cannula support thicknesses maybe varied for one or more associated holes 103 to simulate differentbody wall characteristics (e.g., umbilicus vis-à-vis abdominal muscle).

Piece 201 may be supplied without any perforations, so that piece 201must be pierced to insert a cannula. Alternatively, the piece 201 may besupplied with one or more preformed openings 202 through which thecannulas can be placed. The preformed openings 202 allow piece 201 to bereusable. As shown in FIG. 2A, in some embodiments the preformedopenings 202 may be single slit or cross slit implementations.Alternatively, other openings such as circular shapes of one or morediameters may be used. In some implementations, such as implementationsin foam, a thin protective plastic layer may be placed on top surface203 of piece 201 in order to increase its service life during training.

As illustrated in FIG. 2A, in some embodiments the anatomical model isconfigured to allow cannula support piece 201 to be removable from thetop portion of the model. As shown, a piece 201 can be inserted into asupport bracket 204 that underlies, for example, holes 103 or 104. Apiece 201 can be cut to the shape of a support bracket 204, for example.In some implementations, a piece 201 can be disposable after one or moreuses. The support brackets 204 underlying particular sets of holes maybe identically sized, so that a piece 201 may be inserted into one oftwo or more brackets 204. Alternatively, two or more brackets 204 may bedifferently sized, so that a different cannula support piece 201 isrequired for different corresponding sets of holes. In otherembodiments, a support piece 201 may be permanently attached under a setof holes. In some embodiments one or more support brackets 204 may haveone or more openings 205 that allow a cannula or an instrument to extendthrough the support piece 201 and into the interior space within themodel. In other embodiments, one or more support brackets 204 are solid,so that a cannula or instrument cannot extend beyond the supportbracket.

In some model 101 embodiments, different cannula support types are usedfor different sets of holes. For example, one cannula support type isused for a set of holes used for endoscope insertion, and a secondcannula support type is used for a set of holes used for tissueinstrument insertion. In one example implementation, a foam type cannulasupport is used in association with holes 104, and a different cannulasupport type is used in association with holes 103.

FIG. 2B illustrates a second embodiment of the anatomical model andassociated cannula supports. As shown in FIG. 2B, top portion 102 a isconfigured with a plurality of window openings 206 that are relativelylarger than holes 103 or 104. Each cannula support piece can be insertedin a corresponding support bracket 204 below the surface of top portion102 a and underneath holes 103 and 104, similarly as described above forFIG. 2A. A benefit of such relatively larger window openings 206 is thatthey allow a relatively more free port placement than embodiments inwhich port placement is constrained by the specific locations of theholes 103 or 104. In some embodiments, a thin membrane 207 (shown abovethe top portion 102 a in an exploded view) is placed over the openingsto simulate skin on the model. A pattern of port locations 208 may bemarked on membrane 207, each location being over an opening 206. Variousdifferent membranes 207 may have various different port locationpatterns 208 (e.g., one pattern per membrane, or two or more patternsper membrane) to act as port placement guides for various differentsurgical procedures. Such membranes 207 may also include anatomicallandmarks along with the port placement guides to illustrate spatialrelationships between the ports and the landmarks. In some embodiments,a membrane 207 is used together with an anatomical model having therelatively smaller cannula port placement holes, such as holes 103 and104.

FIG. 3A is a perspective view of another example embodiment of a cannulasupport that may be used in the anatomical model. In one implementationof the anatomical model, a cannula support 301 is aligned with andplaced in each hole 103.

In the depicted implementation, cannula support 301 is a flexible piece(e.g., rubber) sized to fit into holes 103 in the model. Support 301includes grips 302 around the outer perimeter to prevent or reducedislodgement of the support from its associated hole 103. The support301 includes an annular inner membrane 303 that covers a portion of ahole 103, and a hole 304 in the center of the membrane 303. A cannula isinserted through hole 304, and a friction fit between the insertedcannula and the membrane supports the cannula. As described above, acannula inserted through support 301 is a little floppy, which providesrealistic simulation and associated training benefits. Support 301'sdimensions (e.g., thickness) and material characteristics (e.g.,stiffness) may be varied to produce a simulation of different cannulasupport characteristics at various anatomical positions as describedabove.

To assist in training, similar cannula supports 301 may be distinguishedfrom one another by various characteristics, such as markings (e.g.,letters, numbers, and the like) or colors. Supports 301 having aparticular identifying characteristic are placed in certain holes to aidinstruction in proper port locations for particular scenarios. Forexample, in an array of black colored supports 301 in holes 103, redcolored supports 301 may be placed in a first pattern of holes 103 thatcorrespond to proper port placement for a prostatectomy, or the redcolored supports 301 may be placed in a second pattern of holes 103 thatcorrespond to proper port placement for a partial nephrectomy.

FIG. 3B is a perspective view of another embodiment including a cannulasupport 301 and single site piece 310 that may be used with theanatomical model. Cannula support 301 can be similarly implemented asdescribed above for FIG. 3A, which can be designed to accommodate asingle site piece 310. Single site piece 310 can be a supplemental pieceused for guiding multiple cannulas or instruments through a single hole103 or 104. For example, single site piece 310 can be a flexible (e.g.,rubber or similar material) cup-shaped piece as shown in FIG. 3Bincluding multiple holes 312, each hole for guiding a cannula orinstrument, such as a curved cannula 314 inserted in hole 316. In someimplementations, the single site piece 310 can also include an interiorcup portion 320 for securing the single site piece 310 to the anatomicalmodel and/or further guiding the cannulas or instruments. FIG. 3C is aperspective view of an example of three cannulas 322 (disconnected frominstruments and manipulators in this example) inserted through a singlehole of the anatomical model 101 using a single site piece 310.

It should be noted that although anatomical model 101 is generallydescribed as a shell having a hollow interior, with one or more cannulasupports being positioned in relation to the shell so as to support oneor more cannulas inserted through the shell, in some embodiments ananatomical model may be made without a hollow interior so that the modelprovides the cannula support function but not the surgical sitesimulation function. For example, foam or other material may fill theanatomical model's interior. Or, the model may be made of a single,solid piece, such as molded plastic or wood. In such embodiments, asupport piece 201 may be inserted into a corresponding opening in theanatomical model, which acts as a support bracket 204, or other cannulasupports such as supports 301 may be positioned on an outer surface ofthe model with sufficient underlying space to allow a cannula to beinserted into and held by the cannula support.

FIG. 4. is a top perspective view of an embodiment of the anatomicalmodel 101. As shown, top portion 102 a includes several holes 103, andeach hole 103 has a support 301 inserted in it. Top portion 102 a alsoincludes several holes 104, and a portion of a foam piece is placedunder and cover each hole 104. In the depicted embodiment, one or morefoam pieces similar to piece 201 described above are permanently mountedunder each hole 104 (e.g., with screws, as shown), and a protectiveplastic covering 407 is used with preformed cross slits visible overeach foam piece. Thus, the embodiment shown in FIG. 4 is reusable. Threeillustrative operating instrument cannulas 402 are shown placed inassociated supports 301 in holes 103. Although not shown, a camerainstrument cannula may be similarly placed in the foam support at a hole104. A relatively larger hole 104 (not shown) can in someimplementations be placed in top portion 102 a (e.g., at a locationsimulating the umbilicus) to allow training for single port access to asurgical site. In some examples, the introduction of curved cannulas andthe required mounting to an associated robotic manipulator can be tasksthat may require training as provided by anatomical model 101 andmethods described herein.

In some implementations of the anatomical model 101, a top surface 403of top portion 102 a can include one or more marked target locationswhich can act as simulated anatomy locations of a patient. In someimplementations, top surface 403 of top portion 102 a is formed to allowsuch markings to be erasably made (e.g., using grease pencil, whiteboard marker, etc.). Such markings allow a training person to draw on ormark the top portion 102 a to assist training and to help medicalpersonnel understand port placement philosophy, such as to mark portrelationship relative to one another (e.g., operating instrument portspacing from camera instrument port) for various different surgicalprocedures. An overlying membrane, such a membrane 207 (FIG. 2B) may besimilarly made to allow such erasable marking. In other implementations,the marked locations are fixedly made to the top surface for standardsurgical procedures that are commonly trained using the model 101.

In training exercises, the marked locations can be used to determinewhich holes 103 and 104 should be used with reference to the markedtarget locations. In some example implementations of trainee selectionof proper port holes, a location can be marked to simulate a location ofa standard pelvic anatomy feature of a patient, and the trainee then canbe required to determine which of the holes 103 and 104 are to be usedfor cannulas in a particular surgical procedure on that pelvic location.In one example of particular port placements, proper placement of acamera instrument port should be 10-20 cm away from the target location,operating instrument ports should be 8-10 cm from the camera port andother operating instrument ports, and an accessory port should be atleast 5 cm away from other ports. Similarly, another location on topportion 102 a can be marked for an enlarged pelvic anatomy, anotherlocation can be marked for a lateral quadrant anatomy, etc. A trainee'sperformance in properly selecting and placing the cannula ports can bemeasured, as in the training procedures described below.

In some implementations, at least a portion of the outer shell ofanatomical model 101 is made transparent to allow a person being trainedto view a target surgical site within the model's hollow interior andthe relation between the target surgical site the cannula portplacements and robot manipulator positions that are required to properlyreach the target surgical site. For example, top portion 102 a may bemade of a clear plastic material. Likewise, an overlying membrane suchas membrane 207 (FIG. 2) may be made transparent for a similar purpose.

FIG. 5 is a diagrammatic top view of possible port placement grids 501for an overlying membrane. In some implementations, one or more grids501 are placed on a thin membrane 207 that covers top portion 102 a ofthe model. The membrane 207 covers the holes 103,104 (alternatively,window openings 206), and so allows a person being trained to identifyproper port placement in an appropriate hole (or one or more holes) ofthe one or more grids 501. In some embodiments, the membrane includesone or more anatomical features, such as the umbilicus, costal margins,or the xyphoid process, and these anatomical features provide anatomicalreferences that help medical persons understand port placement. Similaranatomical feature markings may be placed directly on the top surface403 of the anatomical model. Such features allow a more realisticsimulation of a patient. Membrane 207 may be marked as a surgeon wouldmark a patient when determining port placement during actual surgery.When port locations are selected on membrane 207, the membrane can bepierced and cannulas inserted though the nearest underlying holes103,104 or through windows 206.

Once cannulas are in place in a patient body wall, a surgical roboticmanipulator can be coupled (“docked”) to each cannula, so that themanipulator controls both the cannula and an instrument that extendsthrough the cannula and into the patient to reach the surgical site.FIG. 6 is a perspective view of an exemplary surgical robot 601 witheach manipulator (one for a camera instrument and three for operationinstruments, as shown) coupled to an associated cannula in theanatomical model. A camera instrument 602 can be positioned through acannula in a centerline hole 104, and the operation instruments 603 arepositioned through cannulas in holes 103, one on one side of the modeland two on the other side of the model (one is partially hidden). Toenhance the simulation of working on a patient in a surgical operatingroom environment, model 101 is placed on an operating table 604 at alocation corresponding to a patient's position on the table. Differentsurgical procedures require various different port placements, and so aperson being trained may have to position the robot 601 in one locationfor one procedure (e.g., at the foot of the operating table as shown,simulating a location between the patient's legs) and in a secondlocation for another procedure (e.g., beside the operating table). Insome implementations, anatomical model 101 may include additionalanatomical features, such as appendages or portions thereof (e.g., legs,arms), other anatomical areas (e.g., head and neck, upper torso), andnatural orifices (e.g., mouth, anus, vagina) to help a person beingtrained understand how patient position and orientation, table positionand orientation, cannula placement requirements, target surgical sitelocation(s), and robotic manipulator position and orientation areinterrelated in order to provide the most effective access to a desiredsurgical site.

In some examples of surgical robotic systems, a trainee surgeon canteleoperate the surgical instruments 602 and 603 from a separate console(not shown) that includes various controls providing signals to thesurgical robot 601 to allow manipulation of the instruments in variousways. For example, various actuators in robot 601 and controlled by theconsole signals can drive movement of the instruments to performsurgical tasks. Other control systems can be used in variousimplementations.

FIG. 7 is a perspective view that shows platform 106 in more detail, andhow platform 106 is positioned within the hollow interior space ofanatomical model 101. In one aspect, various platform 106 embodimentsare made, each embodiment corresponding to one or more differentsurgical procedures at different simulated surgical site locations. Forexample, one platform 106 embodiment may have a simulated surgical sitelocated relatively more cranially than another platform 106 embodimenthaving a simulated surgical site located relatively more caudally. Twoor more simulated surgical sites may be located on a single platform 106to simulate situations in which cannulas must be positioned to provideeffective endoscopic camera and tissue instrument access to the two ormore sites, or to demonstrate that in certain circumstances one set ofcannula positions is required to effectively access one surgical site,and a second set of cannula positions is required to effectively accessa second surgical site. In some circumstances, physical limitations ofthe instruments and/or associated robot manipulators may indicate thatone set of cannula positions required to access one surgical site at afirst anatomical location (e.g., lymph nodes in the lower abdomen), anda second set of cannula positions is required to access a secondsurgical site at a second anatomical location (e.g., lymph nodes in theupper abdomen). Consequently, in such circumstances the robotmanipulators must be decoupled (“undocked”) from cannulas in the firstsetoff positions, cannulas are then inserted in the second set ofpositioned, and the robot manipulators are then docked to the cannulasin the second set of positions.

Platform 106 embodiments may also be configured to place a simulatedsurgical site at various depths within the model so as to simulateworking relatively near the body wall through which the cannulas areinserted (e.g., anterior access to anteriorly located tissue) orrelatively far away from the body wall through which the cannulas areinserted (e.g., anterior access to posteriorly located tissue).

A platform 106 can be removably placed within a fixture (not shown inFIG. 7) in base 102 b, and the fixture acts as a fixed registrationlocation for the associated required port placement. Thus when aplatform is selected and positioned in the model, the platform islocated at a constant position. Thus the model positions surgical taskexercises in the same location inside the abdomen model across surgeonsor between training sessions to enable consistent and repeatablecomparison of trainee performance, and persons being trained can beevaluated to ensure that port placements they select are effective forthe type of surgical procedure being simulated by the selected platform.

As shown in FIGS. 7 and 8, various platform 106 embodiments can each beconfigured to simulate a surgical site. As shown in FIG. 7, for example,platform 106 may be configured with one or more structures at variouslocations, such as pegs 701. FIG. 8 is a perspective view of a platform106 embodiment that is configured with several openings 801 that canaccommodate surgical task training components at various positionsand/or orientations on a platform 106. A simulated surgical task can becarried out by placing one or more objects (e.g., small rings) inrelation to the structures or openings, such that the structures oropenings can act as templates for exercises. In another aspect, a commonplatform 106 is configured to accommodate various removable componentsthat simulate a surgical site. In these aspects, one or more structuresor openings (e.g., pegs 701, openings 801, or holder 902 (FIG. 9)) areused to consistently position removable surgical site simulationcomponents on platform 106 and thus consistently position the componentsin model 101.

FIG. 9 is a perspective view of base portion 102 b with platform 106mounted. Platform 106 is aligned in base portion 102 b by positioning itinside alignment guides 901. A surgical task exercise holder 902 isfixed to platform 106 or may be an integrated part of platform 106.Various surgical task exercise holder 902 embodiments exist, such asguide rails (as shown), releasable fasteners (e.g., hook and loop(Velcro®) fasteners, 3M Company's Dual Lock™ fasteners), magnets,re-adherable adhesives, and the like). Various surgical task exercisecomponents 903 may be inserted into and held by holder 902 at a known,constant position and orientation, so that exercises are consistentlyregistered by location within the anatomical model.

Embodiments of surgical task exercise holders may include two or morecomponents, such as one component coupled to platform 106 and a secondcomponent coupled to the first component. A second surgical taskexercise holder component slides between and is held in place by therails of the first component which is the exercise holder 902 of FIG. 9.A surgical task exercise holder 902 can hold one or more varioussurgical task exercise components. Such surgical task exercisecomponents may be permanently coupled to an associated exercise holder,or they may be removably coupled to an associated exercise holder in amanner similar to the way an exercise holder may be removably coupled toplatform 106.

FIG. 10 is a perspective view of another example embodiment of theanatomical model 101 and a platform 106 similar to the embodiment shownin FIG. 8. Platform 106 includes a surgical site component 1002positioned at one end. The platform 106 can be inserted into an open endof the anatomical model 101 as shown. For example, the platform 106 canbe slid until secured in a known position within the anatomical model101.

FIG. 11 is a perspective view of an example interior of one embodimentof an anatomical model 101. A platform 106 similar to the one shown inFIG. 10 has been inserted and has been secured in a known position withthe interior, thus placing the platform in a known position relative tothe holes 103 and 104 in the top portion of the model 101. In someimplementations, the platform 106 can be secured in the known positionby a plate 1102 that slides into a locking position and is secured inthat position by a fastener, such as knob 1103 which can be screwed inplaced by a trainee. A simulated surgical site including component 1104is provided on one end of the platform 106 and is referenced relative tothree operating instruments 1105 that have been inserted through holes103 and a camera instrument 1106 that has been inserted through a hole104. A trainee can control operating instruments 1105 to manipulate thesurgical site component 1104 similarly to a real surgical site in apatient.

FIG. 12 is a perspective view of one example of an illustrative taskexercise component for a platform 106 similar to the platform 106 ofFIG. 8. Platform 106 of FIG. 12 includes multiple openings 801 which arespaced apart by a predetermined distance in multiple directions. Anexercise component 1201 can include a component base 1202 that holds thesurgical site component 1203 on a top side, and also includes a numberof pegs 1204 on a bottom side of the base 1202. The pegs 1204 are spacedto fit in the openings 801 of the platform 106. In this way, theexercise component 1201 can be positioned in any of a variety of knownlocations on the platform 106. Each of these locations is a knownlocation with respect to the holes 103 and 104. The selected position onthe platform 106 for the component 1201 can be input to the roboticsurgery system, for example. The exercise component 1201 can be any of avariety of types of components as described below.

FIGS. 13A to 13H show several illustrative task exercise componentswhich can be used for platform 106, e.g., as exercise component 903 ofFIG. 9 or any of the surgical site exercise components of FIGS. 10-12.For example, each task exercise component can be removably mounted onholder 902 of FIG. 9 by, for example, sliding under mounting rails 1001of the component 1310 as shown in FIG. 13E. Alternatively, each taskexercise component can be provided on a component base 1202 and insertedin openings 801 of platform 106 as shown in FIG. 12.

Exercise component 1301 of FIG. 13A, component 1302 of FIG. 13B,component 1303 of FIG. 13C, and component 1304 of FIG. 13D involvemoving small pieces such as rings or beads 1305 along a curved pathway,such as a curved wire 1306. These curved pathways 1306 can be orientedvertically (as in components 1301 and 1302), primarily horizontally (asin component 1303), or a combination of these orientations (as incomponent 1304). For example, forceps or claws on the tips of operatinginstruments can be used to grasp the pieces 1305 and move them. In someimplementations, features such as the loops in component 1302 canrequire hand-off by a trainee between two instruments, such as left handand right hand instruments.

Exercise component 1310 of FIG. 13E can be a portion of soft material(e.g., foam) to simulate tissue for manipulation tasks. For example,component 1310 can be a piece 1311 of foam having multiple holes 1312.In some surgical tasks, the trainee can be required to insert a curvedneedle in the holes to perform sutures. FIG. 13F shows a closeup view ofa portion of component 1310 used for a suturing task, where a claw 1313attached to an operating instrument manipulated by a trainee is routinga suture thread 1314 through holes 1312.

Exercise component 1320 of FIG. 13G can include a tubular or ring-shapedportion of soft material (e.g., foam) to simulate a structure oftentreated by surgeons. Tube piece 1321 can be held to the platform 106 bya support 1322. An opening 1323 of the piece 1321 can be exposed toallow a trainee to close the opening with sutures. FIG. 13H shows acloseup view of the tube piece 1321 in which a trainee has closed theopening 1322 with suture thread 1323.

Various exercise components 903 may be used to simulate various surgicaltasks; components of FIGS. 13A-13H are merely illustrative. Theabilities to easily and quickly remove and insert a platform in theanatomical model and change exercise components using platform systemssuch as shown in FIGS. 7-12 allows the anatomical model 101 to be easyto use, offering a large amount of surgical exercises for training whilemaintaining standardized port locations and robot setup across allexercises performed by the trainee.

In some implementations, while a surgical robot is coupled to cannulasinserted in the anatomical model, a platform 106 embodiment may beremoved from the model (e.g., without undocking the robot manipulatorsfrom the associated cannulas or removing the endoscopic camera andtissue instruments from their associated cannulas). Then, either theremoved platform 106 is reconfigured with another exercise component 903or the removed first platform 106 is replaced by a second platform 106with a second exercise component 903, so that a trainee must evaluateport placement in view of a task associated with the reconfigured or newplatform 106. For example, one platform 106 embodiment may representprostate location, which requires one set of port placements, andanother platform 106 embodiment may represent upper abdomen lymph nodelocation, which may require a second set of port placements. Since theplatform 106 positions are the same with reference to base 102 b (i.e.,within the anatomical model), the surgical site locations are in theircorrect relative anatomical locations with reference to the anatomicalmodel. If a trainee chooses an incorrect port placement pattern and isthen required to complete the associated exercise task, the problemsassociated with the incorrect port placement (e.g., robotic manipulatorcollisions, instruments interfering with one another, inability to reachcertain locations at the surgical site, proper camera position forviewing the surgical site during the operation, etc.) are highlightedand evaluated.

The features of the anatomical model allow a trainee to be scored duringthe training process, so that performance and improvement can bemeasured. In addition, a trainee can be scored in relation to othertrainees or in relation to historic data in order to determine how wellthe trainee can perform the required task. Also, aggregate historicalscoring may reveal that trainees have difficulty performing a certaintask, and so training can be modified to improve a training program forthat task.

In some examples, there can be two main categories of the trainingprocess. One skill category can be associated with actions physicallynear the patient's location (e.g., robot manipulator position andorientation setup, cannula port placement, docking, and the like)—socalled “patient side” activities. The second skill category can beassociated with performing the surgical task (e.g., telerobotically ormanually positioning an endoscopic camera and moving tissue instrumentsat the surgical site). Parameters associated with these two categoriesmay be evaluated to measure trainee improvement or to compare onetrainee's performance parameters to corresponding parametersdemonstrated by other trainees (concurrent or historic) or by personsconsidered to have expert skill levels. Thus a trainee's skill level ina particular parameter may be evaluated relative to peers (e.g., todetermine the trainee's progress with reference to anticipatedimprovement) or relative to experts (e.g., to identify deviations from ahigh skill level). For patient side skills training, a trainee may bescored, for example, on how well port placement is selected for aselected surgical procedure, or how long it takes to determine thecorrect port placement. Or, a trainee may be scored on how the surgicalrobot is coupled to the placed cannulas (concerning, for example,manipulator arm collision avoidance) or how long it takes a trainee tocouple the manipulators to the cannulas.

In one aspect, a trainee skill level associated with a specifiedparameter is automatically scored by using information obtained from asurgical robotic system. In a typical surgical robotic system, varioussensors (e.g., joint position sensors, servo motor position encoders,fiber Bragg grating shape sensors, etc.) are used to determine kinematicinformation (position and/or orientation) associated with the robotmanipulators. Consequently, a surgical task exercise scoring system mayuse the robot kinematic information to determine positions andorientations of instruments directed during an exercise, and therebydetermine if a trainee has properly selected ports for a specificsurgical task exercise. As an example of such a scoring system, akinematic setup template is created that defines a specific effectiverobot manipulator position and orientation for a specific surgical task.Data associated with a trainee's surgical task exercise performance iscompared against the template to create a performance score. Forexample, a task exercise time parameter may be measured by starting atimer at the beginning of a cannula docking exercise and stopping thetimer when the surgical robotic system senses that all manipulators havebeen properly docked to an associated cannula. As another example, atask exercise robot manipulator collision avoidance parameter may bemeasured by comparing kinematic information from each docked robotmanipulator against template kinematic information to determine howclose a trainee has come to placing the manipulators in prescribed idealpositions and orientations or within prescribed position and orientationenvelopes. Similarly, kinematic information from the robot manipulators,in conjunction with known physical dimensions of an anatomical model 101(which may be various sizes, as described above) can be used todetermine if a trainee has properly positioned the cannulas in a correctport placement pattern, or if the remote center of motion for eachcannula (the location on each cannula that stays stationary in space asthe manipulator moves) is correctly positioned so as to minimize tissuetrauma at a patient's body wall. For any evaluation, metrics may besampled during the exercise to indicate a trainee's performance as he orshe completes the exercise, and these intermediate evaluations may beplotted against a template to obtain a score. For example, historic datamay indicate that specific acts should be completed in a certain orderin order to most effectively complete a task, kinematic data may be usedto show the actual order in which a trainee performed the acts, anddifferences between the recommended versus actual order of actscompleted is used to determine a trainee's score.

FIG. 14 is a flow chart illustrating an example method for evaluatingsurgical task exercises. The example surgical exercise depicted in FIG.14 is associated with the first category of training categories, patientside (e.g., setup) operations.

In block 1401, an anatomical model 101 is selected, a desired surgicaltask is selected, and a platform 106 associated with the selectedsurgical task is inserted inside the anatomical model. The platform 106is provided with a simulating training exercise site selected to beappropriate for the surgical task and which is positioned on theplatform for port placement appropriate for the surgical task throughthe holes 103 and 104 relative to the site. In block 1402, theanatomical model is positioned on an operating room table. Blocks 1401and 1402 may be performed in any order.

Blocks 1403, 1404, and 1405 are example exercise actions generally forsetting up a robotic surgical task, which are performed by a trainee andmeasured by an evaluation component. In block 1403, a trainee selectsone or more ports for surgery for a specific target anatomy representedby the model. For example, camera cannulas and operating instrumentcannulas can be placed so that the desired surgical site portions are inview of a camera instrument and are in operating range of operatinginstruments to be placed in the cannulas. One or more cannulas can beplaced in one or more of the various holes in anatomical modelembodiments described above, for example. In block 1404, the traineepositions surgical robot manipulators for docking in view of parameterssuch as mutual manipulator collision avoidance and required instrumentrange of motion. In block 1405, the trainee docks the robot manipulatorsto the associated cannulas. During blocks 1403, 1404, and 1405, anevaluation component of the exercise, e.g., implemented by one or moreprocessors of the surgical robot, can measure parameters associated withthe tasks performed by the trainee, such as the overall completion timeof all tasks in blocks 1403 to 1405, completion time of particulartasks, the position and orientation of manipulators, as well as otherparameters of the actions taken by the trainee. Performance parameters(and metrics determined from the parameters) can be measured at multipletimes during the performance of blocks 1403-1405.

In block 1406 an automatic evaluation of the surgical task is completed.For example, the automatic evaluation can use kinematic information fromthe robotic surgical system obtained during the performance of blocks1403, 1404, and 1405. Such kinematic information can use remote centerpositions of the surgical instruments and setup joint values. Thekinematic information can be compared to a template of desired or idealkinematic information to determine if robot manipulator setup joints andother structures are properly configured to place the associated robotmanipulators at a proper position and orientation, and if cannula portsare properly positioned and spaced to allow effective surgical siteaccess with minimized manipulator collision avoidance. The idealtemplate information can be, for example, clustered or averagedpositions, movements, and/or placements from prior performances oftrainees and/or experts, or known optimal positions for instruments,robot components, etc.

As described above, in some implementations, the trainee's performancemetrics for various skill parameters are based on measurements made atmultiple times during the exercise. In some implementations, theindividual trainee's performance can be compared to previous or historicperformance data for that trainee and/or compared to historicperformance data from other trainees and/or from experts to evaluate thetrainee's relative learning speed and effectiveness and/or determinedthe trainee's skill level.

In block 1407, the results of the evaluation are output. In someexamples, the results can be one or more scores that indicate aperformance level or skill of the trainee based on the performance inblocks 1403-1405. Some implementations can provide graphical feedbackindicating the level or skill. For example, graphical diagrams can bedisplayed on a display device indicating how close the robotmanipulators are positioned to ideal or correct positions for thesurgical task. Furthermore, some implementations can output real-timefeedback during the performance of blocks 1403-1405, such as indicatorsof correct or incorrect placements and positions of surgicalinstruments, hints to the trainee, graphical indications of correctpositioning and orientation and the acceptable range of motions andplacements for particular instruments, etc. Some real-time feedback canbe instructional, indicating where instruments should be placed orpositioned. The robotic system, anatomical model, and trainee evaluationfeatures can also be used to provide tutorials to persons, demonstratinghow to select ports, position the robot, and dock robot arms.

In block 1408, various further actions may be taken to continuetraining, such as removing one platform 106 and replacing with a secondplatform 106 or second surgical task exercise, as described above,either with or without undocking the robot manipulators from thecannulas, and then the process may return to 1102 or other earlier blockas appropriate.

Other patient-side tasks can also or alternatively be included in theexercise actions of blocks 1403-1405. For example, static registrationtechniques can be trained, which are used to determine the location ofthe abdomen model in space relative to surgical robot system componentssuch as one or more instruments of the surgical robot 601. In someexamples, static registration can include touching the anatomical model101 in three or more known locations of the model with one of therobotic arms while recording the kinematic information sensed by sensorsof the arms. This kinematic data can be used to determine the 3Dlocation and orientation of the anatomical model relative to the robotsystem. For example, this allows the system to more easily determine theports and model locations which a trainee is using and to providedirected feedback, evaluation, and scoring on such ports and how to moveto the correct ports, if necessary.

FIG. 15 is a flow chart illustrating another example method forevaluating surgical tasks. The example surgical exercises depicted inFIG. 15 are associated with the second category of training categories,surgical task operations performed at the surgical site in theanatomical model.

In block 1501, an anatomical model 101 is selected, a desired surgicaltask is selected, and a platform 106 associated with the selectedsurgical task is inserted inside the anatomical model. The platform hasa training surgical site selected and positioned as appropriate for theselected surgical task. In block 1502, the anatomical model ispositioned on an operating room table. Blocks 1501 and 1502 may beperformed in any order.

In block 1503, a trainee selects ports for surgery associated withspecific target anatomy, inserts the appropriate cannulas into theanatomical model 101, positions the robot manipulators, and docks therobotic manipulators to the associated cannulas. In someimplementations, such patient-side actions can be measured in block1503, as described above with reference to FIG. 14.

In block 1504, the trainee performs the simulated training exercise atthe simulated surgical site inside the anatomical training model byteleoperating the robotic surgical instruments inserted through thecannulas. An example training exercise may be ones illustrated bycomponents of FIGS. 13A-13H described above (e.g., suturing,manipulating objects, etc.), or one or more other simulated tasks. Insome implementations, parameters are measured during the performance ofblock 1504, such as completion time of one or more tasks of theexercise, and robot kinematics for computing metrics (e.g., movementvolume, errors in the exercise, economy of motion of the instruments,etc.). Performance parameters (and metrics determined from parameters)can be measured at multiple times during the performance of block 1504.

In one example, if using a component such as shown in FIGS. 13A-13D atthe surgical site, a training procedure can require that the traineepick up a ring 1305 with an operating instrument, move the ring alongthe pathway 1306 to a finish position (transferring the ring to anotherinstrument controlled by a different hand as needed) without droppingthe ring 1305, while moving the camera to keep the ring and instrumenttips in the center of view at all times, and while repositioningcontrollers to keep the trainee's hands in central controllingpositions. In another example, if using a suturing exercise componentsuch as components of FIGS. 13E-13H, the trainee can be required todrive a needle in a predetermined pathway of suture holes in thecomponent while keeping the site in view of the camera, or suture anopening closed with spatial requirements as to the locations of thesutures.

In block 1505, an automatic evaluation of the surgical task iscompleted. For example, parameters such as overall completion time androbot manipulator movements (e.g., within a particular range of motionenvelope) can be scored against template values considered to be thecorrect parameters. Parameters that may be evaluated may include overallcompletion time, time to complete a particular training exercise and/orone or more stages within an exercise, errors made (e.g., dropping anitem, breaking a suture, etc.) while completing the exercise, the volumecovered by control inputs during the exercise, economy of control inputmotion, and frequency of moving the endoscope instrument during thetask.

In block 1506, the results of the evaluation are output indicating anestimated level or skill of the trainee for the evaluated surgicalexercise. Similarly as described above for FIG. 14, some implementationscan provide graphical feedback, e.g., indicating how close the operatinginstrument end effectors are to ideal or correct positions for thesurgical task, and/or ideal locations for sutures, cuts of tissue, etc.Furthermore, some implementations can output real-time feedback duringthe performance of blocks 1504, such as indicators of correct orincorrect sutures, instrument positions, hints to the trainee, etc. Somereal-time feedback can be instructional, indicating how instrumentsshould be placed, moved, or positioned.

In block 1507, various further actions may be taken to continuetraining, such as removing one platform 106 and replacing with a secondplatform 106 or second surgical task exercise, as described above,either with without undocking the robot manipulators from the cannulas.The process may return to a previous block, e.g., block 1502, 1503, or1504, as appropriate.

Upon completion of an exercise, the metrics may be displayed to thetrainee in the output block 1506 so that the trainee can monitor his orher progress, or can compare his or her performance against otherpersons from a novice to expert range. The anatomical model 101facilitates such automated performance tracking because it allowsrepeatable and standardized placement of simulated training exercisesregardless of instructor or trainee. Current anatomical models areinadequate for such standardized evaluation, and aspects describedherein facilitate the required standardization to ensure that theexercises are identically configured for each use, thus ensuringstandardized training evaluation against peers and experts. In someimplementations, parameters and metrics can be displayed in real-time tothe trainee during the performance of an exercise in block 1504.

Although the above methods in FIGS. 14 and 15 refer to measuring andevaluating performances from a single trainee, these methods can also beused to measure and evaluate performances of multiple trainees at onceand in various roles during a training exercise. For example, theanatomical model and surgical robot system can provide training forteams of persons, such as one or more surgeons, assistants, nurses, etc.In some examples, one or more assistant trainees can performpatient-side surgical tasks for the method of FIG. 14 and a surgeontrainee can perform surgical operations in the method of FIG. 15 whileoperating a console. Trainees other than the surgeon can use the abdomenmodel to practice patient-side skills (e.g. port placement, docking,system setup, camera and instrument insertion) since they will oftenperform these activities in the operating room. The team can also traintheir communication to perform and coordinate various tasks such asexchange instruments, adjust ports, pass sutures using a conventionallaparoscopic tool, coordinate a uterine manipulator to assist theconsole surgeon, etc.

In some implementations providing training for such teams of trainees,the evaluation and scoring methodology described above can be extendedto evaluate the performance of operating room teams in addition toindividual trainees. For example, various scores can be outputindicating the performance level or skill for coordinated team tasks.Such evaluation can be assisted by automated metrics to track progressand compare to historical data similarly as described above. Thesefeatures can help provide proficiency standards for teams to understandtheir efficiency and how they can improve.

The accurate tracking and comparison of a person's skill level asdescribed above in the described training methods can provide importantmetrics useful in a variety of contexts. For example, certifying bodies,such as hospital credentialing committees, may use trainee evaluationsand metrics to decide if a person is qualified for various medicalpractice areas or programs, such as performing robotic or manualminimally invasive surgery or qualifying for medical residency programs.Industry and academic researchers may also use such metrics to determinethe relative effectiveness of various training programs or personnelactions associated with the anatomical model's capabilities, so thatimproved training methods and improved robotic platform configurationsmay be developed. Standardized port placement and exercise positioningas trained using disclosed features allows for comparison betweensubjects and quantification of results that can be included in summarydocumentation submitted to the Food and Drug Administration (FDA) orother governmental or controlling organizations. The standardizationalso allow consistent trainee setups and scenarios to be experienced bydifferent users, enabling understanding of how they use the system andhow certain features of the system can be improved, which in turn can beimportant for required testing of surgical systems as well as designingimprovements to the systems. In a manufacturing context, such techniquesalso allow consistent and repeatable tests for systems coming off of anassembly line and ensure that all such systems are tested the same way.Such techniques also enable certain exercises to be directly replicatedin a computer-simulated environment (e.g., ring manipulation) and usedfor side-by-side comparisons of computer simulation (dry-lab) and thephysical simulation used in the training exercises. This can beimportant for computer simulation development to ensure acomputer-simulated environment represents real world dynamicsappropriately and teaches the trainee the proper skills (e.g., nonegative learning). Direct side-by-side comparisons of this kind havebeen difficult in the past because a standardized setup for the physicalexercises was difficult to achieve.

Furthermore, the anatomical model with multiple port locations enablesclinical development engineers and surgeons to explore and develop newand advanced port placement options for various surgical procedureswithout requiring a porcine model or actual patient. This enables morethorough exploration and understanding of how new and improved portplacements can be discovered. It also can help defineprocedure-recommended port locations for new surgical instruments, newrobotic systems, etc.

FIG. 16 is a diagrammatic view that illustrates aspects of an examplesystem 1600 which can be used for surgical exercise tasks and automatedevaluation and scoring of surgical task exercises. As shown in FIG. 16,a medical device 1601 is used, which can be a robotic surgical system orother system that is capable of providing data concerning the positionand/or orientation of one or more medical devices, such as a systemincluding surgical robot 601. The medical device 601 provides kinematicinformation 1602 to be stored in a memory 1603 that is included in ascoring system 1604. Kinematic information 1602 can include performanceparameters for a trainee's performance, as described above. Information1602 may be provided, for example, via an application program interface(API) interface in a surgical robotic system. The kinematic information1602 can be provided from a patient-side cart component (e.g., includingcannulas, arms, and other features as shown in FIG. 6), and or theinformation 1602 can be provided from other components of the surgicalrobotic system, such as kinematic information describing position and/ororientation of controls for a operator (such as a surgeon or trainee) ona surgeon console used to manipulate surgical instruments provided onthe patient-side cart. For example, such controls can include levers,joysticks, knobs, or other manipulandums movable by the operator in oneor more degrees of freedom.

In some embodiments, anatomical model information 1605 (e.g., physicaldimensions, locations of possible cannula ports, location of surgicalmanipulators or instruments, etc.) associated with an anatomical model101 is also input to the memory 1603. And, template information 1606 isinput into memory 1603, indicating baseline, desired, and/or correctparameters and data for comparison to trainee performance parameters.Other parameter information can also be stored in memory 1603, such asdata processed from kinematic information 1602 and event data, e.g.,recorded times related to trainee tasks and task completions, etc., andwhich can be collected and/or determined by other components of system1600 such as processor 1607, sensors of the system, etc. Thus, memory1603 as depicted is symbolic of one or more physical memory locationsthat can store information that scoring system 1604 uses to carry out anevaluation of a trainee's performance. Such an evaluation is executed byprocessor 1607, which is likewise symbolic of one or more informationprocessing devices (e.g., microprocessor(s) or other processingcircuitry) that can be used to carry out the evaluation.

The evaluation results, such as one or more scores and/or otherinformation, can be output via an output device 1608, such as a visibledisplay on a display screen or other display device, a physical printoutfrom a printer, or other output. The individual exercise results may beadded to historic data 1610 (e.g., depending on an input at operatorselection input 1609), which in turn may be used to modify templateinformation 1606. In some embodiments, an operator input device 1609enables a training system operator to input various selections relatedto training exercises, such as identifying a particular surgicalexercise task to be carried out, and/or identifying a particularanatomical model that is being used. The scoring system canautomatically select the appropriate information (e.g., proper templateinformation 1606) to use to carry out the evaluation.

Embodiments of a scoring system 1604 may be implemented, for example, ona small computer system, such as a laptop computer or other electronicdevice, or they may be embedded in surgical robot systems (e.g., withoutputs displayed via the robot system's displays). Such scoring systemsmay also be networked to a central database to facilitate datacollection from a number of medical devices and from a population ofmedical personnel (e.g., surgeons) and to facilitate data and/or scoringcomparison within the trainee or surgeon population.

In addition to use for robotic surgical system training, variousfeatures disclosed herein may be used for manual minimally invasivesurgery. Scoring aspects for training can be adapted for training insuch manual procedures, such as ability to reach locations at thesurgical site, instrument interference, camera position, surgeoncomfort, etc. Automated scoring aspects can be based on sensing aposition of one or more components, such as cannulas, surgicalinstruments, etc. by various technologies such as machine vision, threedimensional tracking, fiber Bragg grating tether, electromagneticposition sensing, etc.

Features of anatomical models and surgical training methods aredisclosed herein. In various implementations, a standardized anatomicalmodel can provide a known configuration to be used for surgicaltraining. Holes and cannula support pieces can be placed at knownlocations in the model. Various surgical task exercises can be placedinside the interior of the anatomic model at known, consistentlocations. Standardized positioning allows training metrics to bedetermined for various tasks, such as tasks associated with setting up asurgical robotic system to perform a specific procedure on a patient andtasks associated with carrying out the procedure. Training methodsassociated with the use of the standardized model allow specificparameters to be consistently measured for a population of trainees orexperts. A specific trainee's measured parameters can be comparedagainst the measured parameters of peer or expert populations or otherreference data, and an evaluation can be determined and output.Furthermore, many of the metrics that can be captured with the disclosedmodels and methods are far greater in type and scope than what ismeasurable in previous and traditional laparoscopic training exercises.This can be of great advantage for analyzing, improving, and innovatingsurgical procedures and equipment.

In the disclosure herein, the term “flexible” in association with apart, such as a mechanical structure, component, or component assembly,should be broadly construed. In essence, the term means the part can berepeatedly bent and restored to an original shape without harm to thepart. Many “rigid” objects have a slight inherent resilient “bendiness”due to material properties, although such objects are not considered“flexible” as the term is used herein. A flexible part may have infinitedegrees of freedom (DOF's). Examples of such parts include closed,bendable tubes (made from, e.g., NITINOL, polymer, soft rubber, and thelike), helical coil springs, etc. that can be bent into various simpleor compound curves, often without significant cross-sectionaldeformation. Other flexible parts may approximate such an infinite-DOFpart by using a series of closely spaced components that are similar toa snake-like arrangement of serial “vertebrae”. In such a vertebralarrangement, each component is a short link in a kinematic chain, andmovable mechanical constraints (e.g., pin hinge, cup and ball, livehinge, and the like) between each link may allow one (e.g., pitch) ortwo (e.g., pitch and yaw) DOF's of relative movement between the links.A short, flexible part may serve as, and be modeled as, a singlemechanical constraint (joint) that provides one or more DOF's betweentwo links in a kinematic chain, even though the flexible part itself maybe a kinematic chain made of several coupled links. Knowledgeablepersons will understand that a part's flexibility may be expressed interms of its stiffness.

Unless otherwise stated in this description, a flexible part, such as amechanical structure, component, or component assembly, may be eitheractively or passively flexible. An actively flexible part may be bent byusing forces inherently associated with the part itself. For example,one or more tendons may be routed lengthwise along the part and offsetfrom the part's longitudinal axis, so that tension on the one or moretendons causes the part or a portion of the part to bend. Other ways ofactively bending an actively flexible part include, without limitation,the use of pneumatic or hydraulic power, gears, electroactive polymer(more generally, “artificial muscle”), and the like. A passivelyflexible part is bent by using a force external to the part (e.g., anapplied mechanical or electromagnetic force). A passively flexible partmay remain in its bent shape until bent again, or it may have aninherent characteristic that tends to restore the part to an originalshape. An example of a passively flexible part with inherent stiffnessis a plastic rod or a resilient rubber tube. An actively flexible part,when not actuated by its inherently associated forces, may be passivelyflexible. A single part may be made of one or more actively andpassively flexible parts in series.

This description and the accompanying drawings that illustrate featuresand implementations should not be taken as limiting. Various mechanical,compositional, structural, electrical, and operational changes may bemade without departing from the spirit and scope of this description andthe claims. In some instances, well-known circuits, structures, ortechniques have not been shown or described in detail in order not toobscure described features.

Further, this description's terminology is not intended to limit thescope of the claims. For example, spatially relative terms—such as“beneath”, “below”, “lower”, “above”, “upper”, “proximal”, “distal”, andthe like—may be used to describe one element's or feature's relationshipto another element or feature as illustrated in the figures. Thesespatially relative terms are intended to encompass different positions(i.e., locations) and orientations (i.e., rotational placements) of adevice in use or operation in addition to the position and orientationshown in the figures. For example, if a device in the figures is turnedover, elements described as “below” or “beneath” other elements orfeatures would then be “above” or “over” the other elements or features.Thus, the exemplary term “below” can encompass both positions andorientations of above and below. A device may be otherwise oriented(rotated 90 degrees or at other orientations) and the spatially relativedescriptors used herein interpreted accordingly. Likewise, descriptionsof movement along and around various axes includes various specialdevice positions and orientations. In addition, the singular forms “a”,“an”, and “the” are intended to include the plural forms as well, unlessthe context indicates otherwise. Components described as coupled may beelectrically or mechanically directly coupled, or they may be indirectlycoupled via one or more intermediate components.

Elements described in detail with reference to one implementation may,whenever practical, be included in other implementations in which theyare not specifically shown or described unless the one or more elementswould make an implementation non-functional or provide conflictingfunctions. For example, if an element is described in detail withreference to one embodiment and is not described with reference to asecond embodiment, the element may nevertheless be included in thesecond embodiment.

The functional methods, blocks, features, devices, and systems describedin the present disclosure may be integrated or divided into differentcombinations as would be known to those skilled in the art. Disclosedmethods and operations may be presented in a specific order, but theorder may be changed in different particular implementations. In someimplementations, multiple steps or blocks shown as sequential in thisdisclosure may be performed at least partially at the same time.

We claim:
 1. A surgical system comprising: a memory, one or moreprocessors configured to access the memory, and an output device;wherein the one or more processors are configured to perform operationscomprising: measuring one or more performance parameters associated withone or more tasks performed by at least one user, performing anautomatic comparison between the one or more performance parameters andcorresponding one or more stored task parameters associated with the oneor more tasks, and determining an evaluation based on the automaticcomparison; wherein the one or more tasks are performed with referenceto a worksite and a manipulator arm; wherein the one or more tasksinclude positioning of one or more joints of the manipulator armrelative to the worksite to enable a particular range of motion to asurgical instrument of the manipulator arm; wherein the manipulator armis moveable to positions controlled by a control device separate fromthe manipulator arm; wherein the performance parameters includecorresponding one or more positions of the one or more joints of themanipulator arm; and wherein the output device is configured to outputthe evaluation.
 2. The surgical system of claim 1, wherein: the one ormore performance parameters comprise at least one performance parameterbased on kinematic information sensed for the manipulator arm by usingone or more joint sensors sensing the one or more joints.
 3. Thesurgical system of claim 1, wherein: the manipulator arm is one of aplurality of manipulator arms; and the operation of determining theevaluation based on the automatic comparison comprises determiningwhether the positioning of the plurality of manipulator arms will causemanipulator arms of the plurality of manipulator arms to physicallycollide with each other during performance of a surgical procedure inwhich the plurality of manipulator arms is used.
 4. The surgical systemof claim 1, wherein: the worksite is included in an anatomical model;the manipulator arm is one of a plurality of individual manipulatorarms; the one or more tasks comprises placement of a plurality ofindividual ports into the anatomical model; and each one of theindividual ports is configured to receive a corresponding surgicalinstrument connected to a corresponding one of the individualmanipulator arms.
 5. The surgical system of claim 4, wherein: theoperation of determining the evaluation comprises determining whetherthe placement of the individual ports will cause collisions amongst theindividual manipulator arms while each one of the individual manipulatorarms is coupled to a corresponding one of the individual ports during asurgical procedure.
 6. The surgical system of claim 1, wherein: theworksite is included in an anatomical model; the manipulator arm is oneof a plurality of individual manipulator arms; and the one or more taskscomprises docking a plurality of individual surgical instruments, eachconnected to a corresponding one of the individual manipulator arms, tocorresponding individual ports in the anatomical model.
 7. The surgicalsystem of claim 1, wherein: the corresponding one or more stored taskparameters are measured based on a previous performance of the one ormore tasks prior to performance of the one or more tasks.
 8. Thesurgical system of claim 1, wherein: the performance parameters compriseone or more parameters based on sensed kinematic information for themanipulator arm; and the kinematic information comprises position andorientation of the surgical instrument based on sensed joint values ofthe one or more joints of the manipulator arm.
 9. A surgical systemcomprising: a manipulator arm, a memory, and one or more processorsconfigured to access the memory; wherein the manipulator arm is moveableto positions controlled by a control device separate from themanipulator arm; wherein the one or more processors are configured toperform operations comprising: measuring performance parametersassociated with a plurality of tasks, storing the performance parametersin the memory, performing an automatic comparison between theperformance parameters and corresponding stored task parametersassociated with the plurality of tasks, and determining and outputtingan evaluation based on the automatic comparison; wherein each task ofthe plurality of tasks is performed with the manipulator arm withreference to an anatomical model; wherein the plurality of taskscomprises instrument port placement and cannula docking; wherein theinstrument port placement comprises selection of a location on theanatomical model and placement of a cannula at the location; and whereinthe cannula docking comprises coupling of the manipulator arm to thecannula.
 10. The surgical system of claim 9, further comprising anoutput device; and wherein the output device is configured to output theevaluation based on the automatic comparison.
 11. The surgical system ofclaim 10, wherein: the output device is configured to output graphicalfeedback based on the plurality of tasks performed with the manipulatorarm with reference to the anatomical model; and the graphical feedbackindicates one or more correct positions for the manipulator arm whilethe manipulator arm is coupled to the cannula.
 12. The surgical systemof claim 9, wherein: the operation of determining and outputting theevaluation comprises determining whether a remote center of motion forthe cannula is positioned in a predetermined position with reference tothe anatomical model; and the remote center of motion for the cannulaindicates a location with reference to the cannula that remainsstationary in space as the manipulator arm moves in space while coupledto the cannula.
 13. The surgical system of claim 9, wherein: theplurality of tasks comprises an arm setup; and the arm setup comprisesplacement of one or more joints of the manipulator arm relative to theanatomical model to enable a particular range of motion to a surgicalinstrument coupled to the manipulator arm.
 14. The surgical system ofclaim 13, wherein: the manipulator arm is one of a plurality ofmanipulator arms; the arm setup comprises placement of one or morejoints of the plurality of manipulator arms; and the evaluationcomprises a determination of whether the placement of the one or morejoints of the plurality of manipulator arms will cause collisions of oneor more of the plurality of manipulator arms during a first task of theplurality of tasks.
 15. The surgical system of claim 9, wherein: theplurality of tasks comprises contact of the manipulator arm with aplurality of locations of the anatomical model prior to the cannuladocking; and the operations comprise determining a location of theanatomical model in space relative to the manipulator arm by usingkinematic information sensed by one or more sensors of one or morejoints of the manipulator arm at the contact of the manipulator arm withthe plurality of locations.
 16. A surgical system comprising: ananatomical model comprising a surgical site, a surgical devicecomprising a plurality of arms, a memory, one or more processorsconfigured to access the memory, and an output device; wherein each armof the plurality of arms comprises one or more joints; wherein each armof the plurality of arms is moveable to different positions controlledby a control device separate from the plurality of arms; wherein theplurality of arms comprises surgical instruments; and wherein the one ormore processors are configured to perform operations comprising:measuring one or more performance parameters associated with one or moretasks, sensing positions of the plurality of arms by using sensorscoupled to the one or more joints, performing an automatic comparisonbetween the one or more performance parameters and one or morecorresponding stored parameters associated with the one or more tasks,and determining an evaluation based on the automatic comparison, whereinthe one or more tasks are performed by at least one user with referenceto the anatomical model and the surgical device, wherein the one or moretasks comprise placement of ports in the anatomical model for aparticular surgical procedure, wherein the ports are configured toreceive the surgical instruments of the plurality of arms and toposition the surgical instruments with reference to one or moreparticular locations of the surgical site of the anatomic model, whereinthe performance parameters comprise positions of the ports in theanatomical model, and wherein determining the evaluation comprisesdetermining whether the placement of the ports would cause collisionsamongst the plurality of arms while the plurality of arms is coupled tothe ports during the particular surgical procedure.
 17. The surgicalsystem of claim 16, wherein: the operation of determining the evaluationcomprises: determining the placement of the ports in one or moreparticular holes of the anatomical model, and comparing the one or moreparticular holes with a reference pattern of holes associated with theparticular surgical procedure.
 18. The surgical system of claim 16,wherein: the one or more tasks comprise positioning of the plurality ofarms of the surgical device relative to the anatomical model.
 19. Thesurgical system of claim 16, wherein: the one or more tasks comprisedocking of the surgical instruments of the plurality of arms to theports in the anatomical model.
 20. The surgical system of claim 16,wherein: the anatomical model comprises a base portion, a top portioncoupled to the base portion, a plurality of cannula supports, and aplatform removably coupled to the base portion; the base portion forms ahollow space between the base portion and the top portion; the topportion comprises a plurality of holes; each individual cannula supportof the plurality of cannula supports is aligned with one or morecorresponding individual holes of the plurality of holes; the platformcomprises a plurality of attachment mechanisms; each individualattachment mechanism of the plurality of attachment mechanisms is at adifferent location on the platform and is configured to removably attachto a corresponding individual surgical exercise component; and theplacement of the ports comprises placement of one or more cannulas inone or more of the plurality of cannula supports.
 21. The surgicalsystem of claim 16, wherein: the operation of determining the evaluationcomprises: determining whether the placement of ports has placed one ormore camera instrument ports at least a first distance from the surgicalsite, determining whether the placement of ports has placed one or moreoperating instrument ports at least a second distance from the one ormore camera instrument ports and from other operating instrument ports,and determining whether the placement of ports has placed one or moreaccessory ports at least a third distance from other ports.